肱三头肌两侧入路与尺骨鹰嘴截骨入路治疗肱骨髁间骨折疗效对比研究

Comparative study of clinical outcome between triceps sparring and olecranon osteotomy approach in the treatment of humeral intercondylar fractures

目的比较肱三头肌两侧入路与尺骨鹰嘴截骨入路治疗肱骨髁间骨折的疗效差异,为其临床应用价值提供依据。方法回顾性分析2008年9月至2013年9月第二军医大学附属长海医院收治的肱骨髁间骨折患者87例,根据手术方法的不同将其分为观察组(n=45)和对照组(n=42)。观察组患者应用肱三头肌两侧入路进行手术治疗,对照组则使用尺骨鹰嘴截骨入路进行手术治疗。术后比较两组间患者手术时间、术中出血量的情况,并根据Broberg-Morrey肘关节功能评分,分别于术后1、3、6、12个月评估患者肘关节功能。结果随访时间为12个月,失访患者5例,有效随访患者82例,其中观察组44例,对照组38例。(1)两组患者在术后1和3个月患肢肘关节功能评分比较,差异有统计学意义;而在术后6和12个月,两组患者的肘关节功能评分比较差异无统计学意义。(2)观察组患者平均手术时间及平均出血量高于对照组。(3)观察组患者不良反应发生率为9.09%,与对照组的7.89%相比,差异无统计学意义。结论对于肱骨髁间骨折,应首先考虑选择肱三头肌两侧入路,而对于粉碎程度高的C3型骨折,临床技术熟练的情况下仍优先选择经肱三头肌两侧入路。

Background Humeral intercondylar fracture is one of the common complex intra-articular fractures with trochlea affected.It is usually caused by larger force and accompanied by comminution and rotational displacement,which has tremendous impact on the elbow joint function with high disability rate.Due to the poor outcome of manual reduction,open reduction and internal fixation is usually applied clinically. The exposure of fracture is difficult as the elbow joint is complicated with bony block and complex local anatomical structure.Therefore,the correct choice of surgical approach has become the key to the treatment of humeral condylar fractures.The current commonly used surgical approaches are olecranon osteotomy approach,triceps sparring approach and triceps tongue-shaped flap approach. The triceps tongue-shaped flap approach requires triceps transection,resulting in poor strength of elbow extension,plaster external fixation of 3 weeks without early functional exercise,extensive adhesions between triceps brachii and surrounding tissue of distal humerus,and high rate of joint stiffness,which is rarely used in our hospital at present.This paper aims to compare the therapeutic effects of the former two approaches and provide the basis for their clinical application values.Methods From September 2008 to September 2013,87 patients,including 54 males and 33 females were treated for humeral condylar fractures in the orthopedic department of＆amp;nbsp;our hospital.The ages ranged from 21 to 57 years old and the mean age was 35.7 years.According to AO/ASIF classification,26 cases were type C1,39 cases were type C2 and 22 cases were type C3.All patients had a clear history of trauma and were confirmed by X-ray films or CT scans.The patients with surgical contraindications such as hematological disorders,acute infection, severe liver and kidney dysfunctions,etc.were excluded.The causes of fracture included traffic accidents in 37 cases, falling injuries in 27 cases,impact lesions and hit injuries in 14 cases and others in 9 cases.All the patients showed the symptoms and signs of severe pain, swelling, tenderness, abnormal limb activities,bone crepitus and bone friction feeling. According to different surgical methods, the patients were divided into the observation group （45 cases）and the control group （42 cases）.There was no statistical significance but compatibly between two group （P ＆gt;0.05）in the aspects of gender, age, body mass index, bone classification, etc.Operation methods routine examinations and preparations were accomplished preoperatively,and general anesthesia or brachial plexus block was selected as the anesthesia method.Skillful chief physicians who were capable of such operations performed all the surgical procedures.Triceps sparring approach was adopted in the observation group.The patient was in supine position with the affected arm placed in front of chest.The posterior medial incision was made toward the site approximately 3 cm from the distal olecranon.The skin and subcutaneous tissue were cut open in layers to expose the triceps brachii.The muscle groups were bluntly dissected along the medial and lateral triceps.The ulnar nerve was isolated and protected and if necessary,the radial nerve was isolated and protected as well.The triceps was retracted posteriorly to expose the fracture ends.Firstly,the condylar fracture was reduced to simple supracondylar fracture via reduction and fixation with Kirchner wires or lag screws.Secondly,the supracondylar fracture was reduced and temporarily fixed with bone clamps.Lastly,the medial side was fixed with an anatomical plate and the lateral side was fixed with an anatomical plate or a reconstruction plate.The passive motion of joint was satisfactory and the fixation of fracture was reliable.The anterior transposition of ulnar nerve was performed as appropriate.After irrigation and hemostasis,the wound was closed in layers and the drainage tube was placed.The olecranon osteotomy approach was selected in the control group.The skin,superficial fascia and deep fascia were cut open in layers to separate,retracted and protect the ulnar nerve.The triceps tendon was exposed and according to the requirement of olecranon tension band,two thin Kirschner wires were applied to drill two bone tunnels and withdrawn later. The V-shaped osteotomy was performed at the site 2.5-3.0 cm from the proximal olecranon with Koeber′s saw.The dorsal proximal olecranon was lifted to expose the articular surface of distal humerus and debride the intra-articular hematoma and the incarcerated soft tissue.The condylar fracture was turned to supracondylar fracture as the humeral condylar articular surface was reduced and temporarily fixed with Kirschner wire.After the humeral supracondylar fracture was reduced,the medial and lateral locking plates were placed with appropriate screws for fixation under the fluoroscopy of C-arm.The elbow joint was checked for stability of fixation and smooth of articular surface.The osteotomized olecranon was fixed with Kirchner wires and steel wire tension band of 8-shaped cross through the original bone tunnels.The anterior transposition of ulnar nerve was performed routinely. If the ulnar nerve injury was found intraoperatively,the management was conducted according to the damage principles.The wound was closed in layers and the drainage tube was placed.Curative effect evaluation the operation time and blood loss were compared between the two groups.According to Broberg-Morrey elbow function score,the function of elbow joint was respectively evaluated in the postoperative 1st,3rd,6th and 12th months.The total score of Brobery-Morrey elbow function was 100 points,including 40% of range of motion,35% of local pain,20% of muscle strength and 5% of elbow joint stability.The evaluative criteria：≥ 95 was considered excellent,80-94 was considered good,60-79 was considered moderate and 〈60 was considered poor.The postoperative complications were evaluated in the 12th month and compared between the two groups.Statistical analysis the SPSS 21.0 software was used for statistical analysis.The measurement data were presented as x±s .and the t test was used for the comparison between the two groups.The enumeration data was presented＆amp;nbsp;as “percentage”and theχ2 test was applied for the comparison between the two groups.The difference was considered statistical significance with P〈0.05.Results The follow-up time was 12 months and the loss to follow-up occurs in 5 cases.There were 82 cases of effective follow-up,including 44 cases in observation group and 38 cases in control group.Comparison of therapeutic effects between two groups of patients according to Broberg-Morrey elbow function score,the difference of elbow joint function between the two groups in the 1st and 3rd after operation is statistically significant. However,no statistical difference of elbow joint function score was found between the two groups in the postoperative 6th and 12th months.Comparison of operation time and blood loss between two groups of patients.The average operation time of the observation group was （132±25 ）minutes, higher than （91±8 ）minutes in the control group.The blood loss of the observation group was （180±42）ml and higher than （95±28 ）ml of the control group.There is statistical difference between the two groups （P 〈0.05 ）.Comparison of complications between two groups of patients There were 3 cases of severe elbow stiffness and 1 case of myositis ossificans in the observation group and the incidence rate of severe complications was 9.09%.2 cases of severe elbow stiffness and 1 case of nonunion at the site of ulnar osteotomy were found in the control group and the incidence rate of severe complications was 7.89%.The incidence rate of severe complications between the two groups had no statistical difference （P〈0.05 ）.Conclusions Triceps sparring approach and olecranon osteotomy approach are common surgical approaches in the clinical work,and each has merits and demerits.As to humeral condylar fracture,the triceps sparring approach should be the first choice, especially for female patients with weak muscles.However,the olecranon osteotomy approach is an option for surgeons who are not very skilled in the treatment of highly comminuted fracture of type C3.If surgeons can fully grasp the clinical technology,the triceps sparring approach is still considered as a priority.